Repeat Prescription Form

Please remember, we still need two working days to process your prescription request. In line with general practice policy, we cannot take repeat prescription requests over the telephone as the margin for error is huge. Before we can issue some repeat medication safely, checks have to be made (e.g. blood pressure etc for the Oral Contraceptive Pill). Many prescriptions can be requested via the website - please call the practice to check if you are unsure.

For whom are we preparing this repeat prescription ?

Please let us know who you are ...

Name ?
Date of Birth ?

What is your address please ?

If we need to contact you about this prescription request, how can we

contact you ?

Daytime telephone number                  

Evening / weekend telephone number  

Medication details...

Please note that requests for repeats of the  Oral Contraceptive Pill cannot be requested via the website ~ Please call the practice to discuss as an appointment is usually required.

Name of medication ?   

 (this will be on the packet)

Dose ? e.g  mg or  mcg

How much do you take each time ? 

e.g. two capsules, one tablet etc

How often a day do you use this ?

e.g. twice a day, apply once daily etc

What quantity do you require ? 

e.g. 28 tablets or 1 month, 2 months etc    

All prescriptions once completed can be collected from the practice main reception desk 08:00 - 18:00 Mon - Friday (except Public / Bank Holidays). We are only able to post prescriptions if we are in receipt of a stamped addressed envelope at the time of repeat prescription request - if you would like us to post your prescription to you please drop one off at the main reception desk.

Please press the submit button now if you wish to send your request to the surgery. 

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